Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMOThis is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.paramount insurancecompany.com or by calling 1-800-462-3589Important Questions Answers Why this Matters:
What is the overall deductible?
$1,900 individual / $3,800 family. Does not apply to preventive care and prescription drugs.
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy plan or plan document to see when the
deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific services?
Yes, $100 individual / $200 family
for prescription drug expenses. You must pay all of the costs for these services up to the specific before this plan begins to pay for these services. deductibles amount
Is there an out-of-pocket-limit on my expenses?
Yes, for in-network providers
$6,350 individual/$12,700 family. No, for out-of-network providers.
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, and out-of-network services this
plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the
plan pays? No
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a network of providers?
Yes. See
www.paramountinsurance company.com/findaprovider or call 1-800-462-3589 for a list of participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist? No, you don't need a referral tosee a specialist. You can see the specialist you choose without permission from this plan.
Are there services this
Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical
Event Services You May Need
Your Cost If You Use an In-network Provider
Your Cost If You Use an
Out-of-network ProviderLimitations & Exceptions If you visit a health
care provider's office or clinic
Primary care visit to treat an injury or illness $35 Copay/visit Not covered ---None---Specialist visit $70 Copay/visit Not covered
---None---Other practitioner office visit 40% Coinsuranceafter deductible Not covered Spinal Manipulation limited to 12visits per Calendar year. Preventive care/screening/immunization No Charge Not covered
---None---If you have a test Diagnostic test (x-ray, blood work)
40% Coinsurance
after deductible Not covered ---None---Imaging (CT/PET scans, MRIs) 40% Coinsuranceafter deductible Not covered
---None---Paramount Insurance Company: ---None---Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMOCommon Medical
Event Services You May Need
Your Cost If You Use an In-network Provider
Your Cost If You Use an
Out-of-network ProviderLimitations & Exceptions If you need drugs to
treat your illness or condition
More information about
prescription drug coverage is available at www.paramount insurancecompany.com.
Generic drugs Retail: $15 AvgCopay. Mail Order:
$45 Avg Copay Not covered
Coverage limited to a 30 day supply (retail); 90 day supply (mail order). Subject to Deductible.
Preferred brand drugs Retail: $50 Copay.Mail Order: $125
Copay Not covered
Same as Generic drugs. Subject to Deductible.
Non-preferred brand drugs Retail: $100 Copay.Mail Order: $300
Copay Not covered
Same as Generic drugs. Subject to Deductible.
Specialty drugs 4with a maximum of0% Coinsurance
$200 Not covered
Specialty drugs are available through a limited specialty network and not available through mail order program. Subject to Deductible.
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 40% Coinsuranceafter deductible Not covered ---None---Physician/surgeon fees 40% Coinsuranceafter deductible Not covered
---None---If you need immediate medical attention
Emergency room services 40% Coinsuranceafter deductible / visit
40% Coinsurance after deductible /
visit ---None---Emergency medical transportation 40% Coinsuranceafter deductible Not covered ---None---Urgent care $90 Copay/visit Not covered
---None---If you have a hospital stay
Facility fee (e.g., hospital room) 40% Coinsuranceafter deductible Not covered
---None---Physician/surgeon fee 40% Coinsuranceafter deductible Not covered One (1) Inpatient visit per day perPhysican or other Professional Provider
Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMOCommon Medical
Event Services You May Need
Your Cost If You Use an In-network Provider
Your Cost If You Use an
Out-of-network ProviderLimitations & Exceptions If you have mental
health, behavioral health, or substance abuse needs
Mental/Behavioral health outpatient services $70 Copay/visit Not covered ---None---Mental/Behavioral health inpatient services 40% Coinsuranceafter deductible Not covered ---None---Substance use disorder outpatient services $70 Copay/visit Not covered ---None---Substance use disorder inpatient services 40% Coinsuranceafter deductible Not covered
---None---If you are pregnant
Prenatal and postnatal care No Charge Not covered ---None---Delivery and all inpatient services 40% Coinsuranceafter deductible Not covered
---None---If you need help recovering or have other special health needs
Home health care 40% Coinsuranceafter deductible Not covered 100 Visit(s) per Year
Rehabilitation services 40% Coinsuranceafter deductible Not covered Inpatient limited to 60 days per year.Outpatient therapy services limited to 20 visits per therapy type.
Habilitation services 40% Coinsuranceafter deductible Not covered Habilitative services benefits shall bedetermined by the individual plans. Skilled nursing care 40% Coinsuranceafter deductible Not covered 90 Days per Year
Durable medical equipment 40% Coinsuranceafter deductible Not covered ---None---Hospice service 40% Coinsuranceafter deductible Not covered
---None---If your child needs dental or eye care
Eye exam $70 Copay/visit Not covered 1 Visit(s) per Year
Glasses No Charge afterdeductible Not covered Lenses and contacts: 1 Item(s) perYear. Frames: 1 Item(s) per 2 Years. Dental check-up Not covered Not covered
---None---Paramount Insurance Company: ---None---Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMOExcluded Services & Other Covered Services
Services Your Plan Does Not Cover(This isn't a complete list. Check your policy or plan document for other excluded services .) • Acupuncture
• Dental care (Adult) • Long-term care
• Bariatric surgery • Dental care (child) • Routine foot care
• Cosmetic surgery • Hearing aids
• Weight loss programs
Other Covered Services(This isn't a comlete list. Check your policy or plan document for other covered services and your costs for these services.)
• Chiropractic care • Private-duty nursing
• Infertility treatment • Routine eye care (Adult)
• Non-emergency care when traveling outside
the U.S.
Your Rights to Continue Coverage
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:
• You commit fraud
• The insurer stops offering services in the State • You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-800-462-3589. You may also contact your state insurance department at The Ohio Department of Insurance, 50 W. Town Street Third Floor - Suite 300 Columbus, Ohio 43215 Phone:(800) 686-1526.
Your Greivance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: The Ohio Department of Insurance, 50 W. Town Street Third Floor - Suite 300 Columbus, Ohio 43215 Phone:(800) 686-1526.
Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMODoes this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-462-3589
Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014Coverage Examples Coverage for: Individual/Family | Plan Type:HMO
About these Coverage
Examples:
These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
This is not a cost
estimator.
Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these
examples, and the cost of that care will also be different.
See the next page for important information about these examples.
Having a baby
(normal delivery)■ Amount owed to providers: $7,540 ■ Plan pays $3,370
■ Patient pays $4,170
Sample care costs:
Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40
Total $7,540
Patient pays:
Deductibles $1,920
Copays $70
Coinsurance $2,030
Limits or exclusions $150
Total $4,170
Managing type 2 diabetes
(routine maintenance of a well-controlled condition)■ Amount owed to providers: $5,400 ■ Plan pays $2,310
■ Patient pays $3,090
Sample care costs:
Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700
Education $900
Laboratory tests $500 Vaccines, other preventive $40
Total $5,400
Patient pays:
Deductibles $2,000
Copays $840
Coinsurance $170
Limits or exclusions $80
Paramount Insurance Company: Paramount HMO Silver
Coverage Period: 1/1/2014 - 12/31/2014Coverage Examples Coverage for: Individual/Family | Plan Type:HMO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
• Costs don’t include premiums.
• Sample care costs are based on national
averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.
• The patient’s condition was not an excluded
or preexisting condition.
• All services and treatments started and
ended in the same coverage period.
• There are no other medical expenses for
any member covered under this plan.
• Out-of-pocket expenses are based only on
treating the condition in the example.
• The patient received all care from
in-network providers. If the patient had received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage Examples helps you see how deductibles,
copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.
Does the Coverage Example predict
my own care needs?
No
. Treatments shown are just examples. Thecare you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.
Does the Coverage Example predict
my future expenses?
No
. Coverage Examples are not costestimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.
Can I use Coverage Examples to
compare plans?
Yes
. When you look at the Summary ofBenefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.
Are there other costs I should
consider when comparing plans?
Yes
. An important cost is the premiumyou pay. Generally, the lower your
premium, the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.
